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Healthy business?

Healthy business?

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GPs have 60 years' experience of working in
small businesses. Many think and act and feel like business
people. Successive governments have sought to harness that
entrepreneurial spirit to help deliver their policy objectives
– and the new Tory/Lib Dem coalition is no different. But
while (almost) everyone accepts that change is necessary, are
GP entrepreneurs really the panacea the government would
have everyone believe?

Entrepreneurs, by definition, "organise business ventures
GPs have 60 years' experience of working in
small businesses. Many think and act and feel like business
people. Successive governments have sought to harness that
entrepreneurial spirit to help deliver their policy objectives
– and the new Tory/Lib Dem coalition is no different. But
while (almost) everyone accepts that change is necessary, are
GP entrepreneurs really the panacea the government would
have everyone believe?

Entrepreneurs, by definition, "organise business ventures
and assume risk for them". The health white paper, published
in July, calls on GPs to channel these skills by creating
commissioning organisations that are GP-led and are, in
effect, businesses. (Granted, this is undermined by suggestions
these 'consortia' could be statutory bodies, but we'll leave
that to one side for now.) As well as taking the lead at practice
level, entrepreneurial GPs could also become the accountable
officer for their consortium, assuming legal responsibility
for overspends and underperformance, and taking control
of the overall strategy for dozens of other practices in their
region. GPs are also likely to have roles in overseeing groups
or federations of consortia. And they could even operate at a
national level in the new NHS Commissioning Board, which
will oversee the consortia themselves.

A precedent for giving GPs greater purchasing power produced some uneven results, however. The GP fundholding
programme introduced in the early 1990s led to higher
managerial and transaction costs because GPs had to spend
much of their time negotiating with hospitals, while hospitals
had to spend more time and money negotiating with them.
More seriously, though, data suggests fundholding may
actually have led to a drop in patient satisfaction. (One
explanation for this unhappiness is that GPs were spending more time working as managers and less time dealing with patients.)

However, there's proof of GPs excelling at commissioning,
too. Studies show that fundholding reduced pharmaceutical
use, lowered elective referral rates and allowed GPs to make
some savings by lowering the demand for clinical services.
And there are more recent examples of entrepreneurial
GPs innovating in this field, such as Colchester Practice-
Based Commissioning (PBC) Group who won last year's MiP
Business Management Award. The group developed the
"Pulsebeat" scheme that involved commissioning a network of
37 GP practices in north-east Essex to take the pulse of every
patient over 65 attending for their flu vaccination, with the
aim of identifying people with atrial fibrillation (AF), a strong
risk factor for stroke. The scheme was a huge success.

"We detected 249 new cases of AF that hadn't been
diagnosed previously," said Dr Shane Gordon, Chief Executive
of the PBC group and GP at Tiptree Medical Centre in Essex.
"We estimate from published figures that by treating those
patients we will prevent approximately nine strokes in the next
year." The project also proved to be highly cost-effective, with
a return on investment of 400%.

In parallel to the commissioning consortia, the white
paper sketches out a greater role for entrepreneurial GPs
as part of the government's plan to further 'open up'
healthcare services so that "any willing provider" (AWP)
can deliver them – presumably, in primary care, through an
expansion of the "alternative provider of medical services"
(APMS) contracting route.

APMS was established so that commissioners can contract
with a wide range of providers outside of the traditional NHS 'family'. Some of the successful bidders for these deals have
been 'normal' GP practices or locally based consortiums;
some were divisions of international healthcare companies;
and the rest were organisations formed by entrepreneurial
GPs – either as companies in their own right or as joint
ventures with commercial organisations. Many GP owners
do not work in the practice and some are GPs in name only,
providing no direct patient care.

And while anecdotal evidence suggests some GP-led APMS
firms are good employers providing high standards of care,
others exhibit the worst practices of the private sector. In at
least a few organisations, salaried doctors have to work long
surgeries and antisocial hours. A high nurse-to-doctor ratio
and patient triage means some doctors see only complex
cases, and within 10-minute timeslots.

In some areas, doctors may be moved from practice to
practice at short notice, giving them little chance of getting
to know either the patients or the area. And there have
been allegations that in some practices there are no senior
colleagues working alongside younger doctors, few clinical
or team meetings, and little or no autonomy. Of course, all
this can eventually have a detrimental impact on quality and
continuity of patient care.

There are numerous successes, though. One Medicare,
for example, a primary care group set up by GPs, opened
its Sheffield City GP Health Centre just over a year ago.
It's open 8am to 8pm, seven days a week, 365 days a year,
has seen thousands of patients on a walk-in basis and 6,000
patients have registered with the surgery. Anyone can walkin
and receive NHS healthcare without being registered;
people who live locally can register with the surgery if they
wish. Patient survey data for the centre registers an overall
patient satisfaction rating of 95%. Failures are inevitable
in a marketplace, say AWP's supporters, but they are far
outweighed by the overall improvement that is driven by
competition between providers. "The market is what forces
people to perform," said Tim Care, a partner in the public
services practice at law firm Dickinson Dees.

Indeed, according to recent research by the
London School of Economics' Centre for Economic
Performance, increasing competition in the NHS is
vital to improving quality and efficiency – just as it is in
other sectors of the economy. The key is to have efficient
accountability measures in place to ensure the failing
body is identified quickly. "There should be checks and
balances in place. In order to do that, there needs to be
competition so the best can rise to the top," said Mr Care.

But while there are plenty of examples of entrepreneurial GPs excelling at both commissioning and APMS, are there enough doctors who actually want to emulate them? Many GPs simply don't agree with the competition principles that are the white paper's subtext.

Recent work by the King's Fund think tank found that
although more than 75% of patients were extremely keen
to have a choice, GPs did not regard choice as imperative
for patients. Indeed, GPs were reluctant to offer patients
their private sector options for care and, in some cases,
were reluctant to offer patients any choice whatsoever when
specialist treatment was required.

Moreover, plenty of GPs don't want to sacrifice their
surgery time. It's easy to envisage a situation, for example,
where some GPs could be heavily engaged in new consortia
and spending less and less time with patients, growing
frustrated with doing the work that primary care trusts used
to do, or managing new APMS facilities.

Even if GPs are prepared to take up a more managerial
role, how many are going to be willing to shoulder
commercial risks? While the financial gamble associated
with setting up a new APMS provider is obvious, there's
also talk of GPs taking some benefit from commissioning
surpluses and incurring penalties for overspends.

"If GPs are to take profit from successful use of public
money, that they should be personally at financial risk is
a reasonable argument," said Dr Shane Gordon. "But I
think there is a question about how much risk they are
exposed to. Putting their entire livelihood on the line is
probably not a reasonable thing to do. No one has actually
succeeded at commissioning yet, after all."

Time will tell if the government can put together a
remuneration package that will encourage sufficient
entrepreneurial GPs to lead consortia, and whether GPs
are prepared to take on private healthcare companies or
established local providers for APMS contracts.

The stark reality is that the NHS will have to make savings
of more than £20bn. Someone has got to make the health
service do more for less, and GPs look best placed to do it.

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